Provider Demographics
NPI:1588046312
Name:RESTORE PSYCHOLOGICAL AND COUNSELING SERVICES
Entity type:Organization
Organization Name:RESTORE PSYCHOLOGICAL AND COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:216-310-8471
Mailing Address - Street 1:5601 BRIDGE ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-2384
Mailing Address - Country:US
Mailing Address - Phone:682-593-1475
Mailing Address - Fax:817-492-7001
Practice Address - Street 1:5601 BRIDGE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-2384
Practice Address - Country:US
Practice Address - Phone:682-593-1475
Practice Address - Fax:817-492-7001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-29
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70803251S00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty